ECLS in Pediatric Cardiac Patients

Abstract

Extracorporeal life support (ECLS) is an important device in the management of children with severe refractory cardiac and or pulmonary failure. Actually, two forms of ECLS are available for neonates and children: extracorporeal membrane oxygenation (ECMO) and use of a ventricular assist device (VAD). Both these techniques have their own advantages and disadvantages. The intra-aortic balloon pump is another ECLS device that has been successfully used in larger children, adolescents, and adults, but has found limited applicability in smaller children. In this review, we will present the "state of art" of ECMO in neonate and children with heart failure. ECMO is commonly used in a variety of settings to provide support to critically ill patients with cardiac disease. However, a strict selection of patients and timing of intervention should be performed to avoid the increase in mortality and morbidity of these patients. Therefore, every attempt should be done to start ECLS "urgently" rather than "emergently," before the presence of dysfunction of end organs or circulatory collapse. Even though exciting progress is being made in the development of VADs for long-term mechanical support in children, ECMO remains the mainstay of mechanical circulatory support in children with complex anatomy, particularly those needing rapid resuscitation and those with a functionally univentricular circulation. With the increase in familiarity with ECMO, new indications have been added, such as extracorporeal cardiopulmonary resuscitation (ECPR). The literature supporting ECPR is increasing in children. Reasonable survival rates have been achieved after initiation of support during active compressions of the chest following in-hospital cardiac arrest. Contraindications to ECLS have reduced in the last 5 years and many centers support patients with functionally univentricular circulations. Improved results have been recently achieved in this complex subset of patients.

Keywords: ECMO; VAD; children; heart failure; neonates.

Figure 1

Annual neo/ped ECMO runs. (International Summary 2016. Courtesy of P. Rycus from the ELSO Registry).

Figure 2

Cardiac Runs by diagnosis: % of survival on ECMO. Avg, average.

Figure 3

ECLS in single-ventricle physiology: first stage support with Blalock–Taussig (BT) shunt using ECMO or VAD according to patient’s gas exchange. Technical aspects: to better support first stage hypoplastic left heart syndrome the BT shunt should be narrowed to avoid pulmonary overflow. SVC, superior vena cava; IVC, inferior vena cava; PV, pulomanry veins; TV, tricuspidal valve; RV, right ventricle; LPA, left pulmonary artery; RPA, right pulmonary artery; Ao, aorta (courtesy of Dr. Massimo Griselli).

Figure 4

ECLS in single-ventricle physiology: second stage support (Glenn Physiology) using ECMO or VAD according to patient’s gas exchange. Technical consideration: the inflow cannula can be atrial or ventricular (courtesy of Dr. Massimo Griselli).

Figure 5

ECLS in single-ventricle physiology: third stage support (Fontan Physiology) using ECMO or VAD according to patient’s gas exchange (courtesy of Dr. Massimo Griselli).